Topic 9: Behavioral Exposure and CBT Case Formulation & Treatment Plan {by 11/7}

[Behavioral Exposure] – Watch PDA-6: Behavioral Exposure – Assessment of Anxious Patterns.  Answer the following (you can be brief): (1) What was the client’s primary negative automatic thought (possible cognitive distortion?) in response to this event?  (2) What was the client’s response to her associated automatic thoughts and physiological arousal (any safety behaviors?)?

 

[Case Formulation & Treatment Plan] – There are multiple readings due this week (J. Beck – 2 Chapters & Appendix A; Volungis – 1 Chapter; Persons & Tompkins [2006]; Academy of Cognitive Therapy: Candidate Handbook – Appendix D & E).  For this discussion, share at least two main thoughts: (1) Why is a CBT case formulation important for effective therapy (i.e., how does it help clients get “better”)? (2) Why is it necessary to have specific, concrete, and measurable treatment goals whenever possible?  Your original post should be posted by the beginning of class 11/7.  Have your two replies no later than 11/9.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

25 Comments (+add yours?)

  1. Zacharie Duvarney
    Nov 01, 2019 @ 11:37:58

    Behavioral Exposure

    1.

    – The client was tasked with going to the grocery store independently. As is evident by her accounts of the experience, she experienced several negative automatic thoughts. Primarily, the client felt that she was too ambitious in her attempt of going out in public, which resulted in feelings of failure. Her feelings of failure may be the result of a cognitive distortion, specifically, selective attention to negative details. Although the client had to leave the store due to her intense physiological arousal, she still attempted the behavioral experiment. This attempt alone should be seen as a success and evidence against the idea that she is a failure. In fact, the therapist explicitly states this fact, assuring the client that her attempt alone was impressive.

    – Aside from feeling she was too ambitious in her attempt; the client experienced several other negative automatic thoughts. After noticing that she was succumbing to distressing physiological arousal, she had the negative automatic thought of “I am losing control”. Consequently, the client began to take notice of the people around her and began worrying about how others would react if she fell victim to an intense panic attack. This led to the concern that she wouldn’t be able to escape the store, a hallmark feature of agoraphobia. All in all, we can see how one negative thought led into another, perpetuating the panic attack and ultimately resulting in the client fleeing from the anxiety-provoking situation.

    2.

    – As the client’s physiological arousal and cognitive distress increased, she felt the need to flee from the grocery store, which acted as negative reinforcement for her fear response. She states that she ran to the car, where her husband was waiting. After reviewing the entire therapy sessions, it is clear that going to her husband in times of distress is the client’s safety behavior. The therapist recognizes this, as he explicitly states that the client will eventually have to fade her husband’s involvement out of her exposure experiences. In order to break the cycle of negative reinforcement, the client will have to attempt in vivo exposure independently, regardless of the result. If the intervention works as intended, she will eventually be able to cope with her negative automatic thoughts and physiological arousal. The development of effective coping mechanisms is a prerequisite to conquering her panic attacks on a cognitive level.

    Case Formulation & Treatment Planning

    1.

    – Accurate CBT case formulation is a prerequisite to successful treatment planning and intervention (Beck, 2011; Volungis, 2019). CBT case formulation consists of identifying precipitating factors, maladaptive thought patterns, and longitudinal information (Volungis, 2019). By analyzing these factors together, therapists can interpret clients’ presenting problems and associated symptoms using the cognitive model (Beck, 2011; Volungis, 2019). Furthermore, case formation will be the driving force behind treatment planning and implementation of interventions, making it a necessary step in the therapeutic process.
    – Case formulation is often the first step in building therapeutic rapport and establishing collaborative empiricism (Volungis, 2019). Clients feel like they are being heard and understood when they participate in case formulation, which reinforces rapport. Also, having the client actively participate in case formulation can be a form of psychoeducation, given that the client is learning more about their presenting concerns.
    – Case formulation is required to arrive at a diagnosis, which is essential in managed care environments. Your case conceptualization will eventually lead to a working hypothesis, which will be refined into a DSM-V diagnosis (when applicable). Having a formal diagnosis is not only necessary for managed care but will also inform and drastically improve treatment planning.

    2.

    – Having highly specific treatment goals facilitates the remission of a client’s disorder and prevent relapse (Beck, 2011). If the therapist endeavors to identify and tease apart each presenting problem in detail, they will develop accurate conceptualizations and highly specific goals (Beck, 2011). By having specific treatment goals, the therapist will be able to tailor treatment as whole, as well as between sessions.
    – Specific and concrete goals assist the therapist in measuring client progress. It is suggested that goals be constructed in an empirical manner. For example, a goal of “reducing depression symptoms each week as evidenced by Beck Depression Inventory scores” is better than “feel less sad” (Volungis, 2019). By constructing empirical goals, the therapist can employ assessments to track progress. This will not only help reassure the client that they are making progress but will also assure third party payers that you are doing your job. Managed care demands that therapists put forth evidence of client progress. Therefore, having highly specific treatment goals is conducive to succeeding in the managed care arena.
    – All in all, empirical and concrete treatment goals are essential in treatment planning, implementing effective interventions, and tracking client progress. CBT clinicians endeavor to understand clients’ problems in a scientific manner, and this should be reflected in treatment goals.

    Reply

    • Bianca Thomas
      Nov 07, 2019 @ 09:48:54

      Zacharie, I agree with your thought that Lindsay’s negative automatic thought may be the result of a cognitive distortion to selective attention to negative details. She saw her attempt as a failure instead of a success of the desire to try to overcome her fear.

      The client seeking out her husband is definitely a safety behavior she has created, and the phasing out of the husband and the development of effective coping strategies is absolutely her best chance at overcoming her panic attacks.

      Reply

  2. Katrina Piangerelli
    Nov 05, 2019 @ 14:36:37

    [Behavioral Exposure] – Watch PDA-6: Behavioral Exposure – Assessment of Anxious Patterns. Answer the following (you can be brief):
    (1) What was the client’s primary negative automatic thought (possible cognitive distortion?) in response to this event?

    Lindsay had multiple negative automatic thoughts in response to going to the crowded grocery store, including the notion that going to the grocery store by herself was too ambitious. Much of what Lindsay was thinking dealt with issues such as being unable to escape, what happens if she has a heart attack, and feeling like she was losing complete control. This all resulted in Lindsay ultimately feeling like she had failed in her task of going to the grocery store. The feelings of failing may be part of a cognitive distortion as she focuses on the negative outcomes and what she did wrong, rather than on her successes. The therapist in this specific instance explains that she did a great job of going to the grocery store by herself, and was impressed that she tried to do this on her own so early in treatment. Despite her feeling like this was a major failure, the therapist shows her that this was not a complete loss and that she did achieve some of what she wanted to, even if it was not perfect and the end result was her leaving. Once Lindsay began to feel panicked, another negative automatic thought of feeling as though she is losing complete control began to take over her thoughts. This led Lindsay to think that she could have a heart attack at the grocery store. She also became much more aware of all of the people around her, feeling as if they were watching her, and that she was not able to escape from this situation.

    (2) What was the client’s response to her associated automatic thoughts and physiological arousal (any safety behaviors?)?

    Lindsay’s response to her automatic thoughts and physiological arousal was to leave the grocery store. Lindsay automatically went to the car where her husband was and they went straight home. The negative safety behavior that is most obvious in this specific example is Lindsay’s husband, as he came to the grocery store with her and waited in the car. The therapist shares that this is something that they will have to work on and that her husband will slowly need to fade away from these scenarios.

    [Case Formulation & Treatment Plan] – There are multiple readings due this week (J. Beck – 2 Chapters & Appendix A; Volungis – 1 Chapter; Persons & Tompkins [2006]; Academy of Cognitive Therapy: Candidate Handbook – Appendix D & E). For this discussion, share at least two main thoughts:
    (1) Why is a CBT case formulation important for effective therapy (i.e., how does it help clients get “better”)?

    The CBT case formulation is important for purposeful, efficient, and effective treatment planning. CBT case formulation should include a collaborative effort by both the therapist and the client for effective treatment. For the case formulation, there are several components. The first is precipitating and maintaining factors summary, which includes focusing on what the client has done in the past to cope with distress, even if they were not effective methods. Another component is the cross-sectional view of cognitions, emotions, and behaviors, which focuses on automatic thought patterns that are recognized in earlier sessions. The third component is the longitudinal view of cognitions, emotions, and behaviors, which develops as the client’s core beliefs emerge and are better understood by the client and therapist. Then there is a working hypothesis, which is a summary of the CBT case formulation, and the focus is on the presenting problems and symptoms of the client. Including strengths and assets in the working hypothesis and as a part of the case formulation is beneficial and can significantly increase treatment motivation, engagement, and effectiveness. At the end of the case formulation, a DSM diagnosis is required. This can help to provide guidance in the direction of treatment, but distress and the impact this has on functioning is ultimately the most important factor in determining the direction of treatment.

    (2) Why is it necessary to have specific, concrete, and measurable treatment goals whenever possible?

    Treatment goals are the outcomes that the client wants, and they should also indicate progress made by the client. This will be shown through a decrease in symptoms and an overall improved quality of life. The goals should be objective and measurable in order to track treatment and progress of the client and their care. If an assessment is more frequent and accurate, it will correspond with the treatment being more effective. It is also important to show that there is progress being made in the treatment for managed care purposes. Interventions are focused on what needs to be done in order to achieve a goal. This means that an intervention should be linked to a goal, providing a clear perspective of how the therapy is progressing. The intervention should also be specific to the client and descriptive in nature. It may also be beneficial to briefly describe how an intervention will actually be applied.

    Reply

    • Zacharie Duvarney
      Nov 05, 2019 @ 16:36:01

      Katrina,

      In your response to question 1, you discussed how Lindsay’s therapist reinforced her strengths in an attempt to minimize her feelings of failure. Specifically, the therapist commended Lindsay for attempting to go into the grocery store by herself, despite the fact that Lindsay felt like she failed in this attempt.

      It is important to recognize clients for the hard work they do, no matter the result. Too often in therapy, therapists focus on the client’s weaknesses and failed attempts at adaptive behavior. It is crucial that we recognize how hard it is to implement behavioral change in our lives. Furthermore, reinforcing client’s strengths usually improves the effectiveness of therapy.

      Reply

    • Adam Rene
      Nov 07, 2019 @ 11:12:58

      Katrina –

      Thank you for your post. I saw several similarities amongst our responses to this blog post. In particular, I appreciated how you included assessments in your response when discussing treatment plans and how the results of assessments should coincide with treatment progress (or lack thereof). I know in previous courses we’ve discussed the importance of continued assessment, not just at the beginning or at the end, to depict and calculate progress made in therapy.

      Reply

  3. Paola Gutierrez
    Nov 06, 2019 @ 08:47:01

    Assessment of Anxious Patterns – Lindsay video

    1. Lindsay had several negative automatic thoughts associated with the behavioral exposure of going to the grocery store alone. The first was Lindsay’s comment that the task was an overly ambitious one. While the exercise may indeed have been too intense for the beginning of treatment, Lindsay sold herself a little short considering that, according to her, it had been months since she’d been inside a grocery store. The therapist commented that the exposure exercise may have been beyond her capability at the present time, he gave her credit for attempting the exposure exercise. In some ways, Lindsay’s initiative in that exercise demonstrates her motivation for change. She also had some cognitive distortions, such as “black-and-white” or “all-or-nothing” statements that generalized the situation. For example, she used statements like “too ambitious” and “it was a failure.” She was clearly disappointed that the behavioral exposure didn’t go as well as she’d hoped. Instead of viewing her ability to even step into the grocery store as a marked improvement from before, she filtered out those details and focused on the negative aspects of the experience. She also had negative automatic thoughts at the moment that were connected to the symptoms of a panic attack, such as fear of losing control, fear that she was having a heart attack, and not being able to escape.

    2. As Lindsey was in the grocery store, she could feel the physical symptoms of a panic attack (chest tightness, body warming up, etc) and even though intellectually she was aware that she was not having a heart attack, she felt that she was losing control, there was no escape, and that she needed to flee. As soon as she saw her husband, the physiological arousal decreased. The therapist identified the client’s husband as a safety behavior that interferes with the effectiveness of behavioral exposure. The husband’s presence will need to be phased out so that the client can complete behavioral exposure exercises independently.

    CBT Case Formulation & Treatment Planning

    1. A CBT case formulation comprises several components of a client’s life, including presenting problems, cross-sectional and longitudinal views of a client’s thoughts, emotions, and behaviors that have contributed to distress, any stressful life events or current stressors that influence current distress, and DSM diagnosis. A well put-together case formulation gives therapists a clear picture of what is likely going on with their client that will inherently guide the treatment plan and the interventions that are implemented. Case formulations are, in other words, crucial for developing a strong treatment plan, and without an effective treatment plan, therapy is unlikely to be effective. CBT case formulations are also modified throughout treatment in accordance with the client’s progress and additional information that is collected during treatment. The case formulation exemplifies an individualized approach to treatment that is tailored to the client’s needs and presenting problems. Lastly, case formulations are meant to be a collaborative process between therapist and client, thereby strengthening the therapeutic relationship and maintaining the collaborative empiricism element of CBT that plays a role in making therapy effective.

    2. Identifying goals that are specific, concrete, and measurable allow for an evaluation of progress that is tangible and clear. For example, the example of “be more social” does not allow for a comparison to be made when evaluating a client’s progress. On the other hand, the goal of “the client will initiate conversations with peers at least twice a week” provides a clear point of comparison. Specific treatment goals can be readily assessed whereas vague or nonspecific goals cannot be measured. Secondly, better goals translate to better interventions. These interventions will also likely be more specific and can be examined for effectiveness. Having specific, concrete, and measurable goals make therapy more effective for clients because they allow for better assessment of progress.

    Reply

    • Bianca Thomas
      Nov 07, 2019 @ 09:44:21

      Paola, I agree with your statement that Lindsay had sold herself short considering that it had been months since she’d been inside a grocery store. Her assumption of herself as a failure only precipitated her negative beliefs of herself and probably made her feel less confident in wanting to try that experiment again.

      Lindsay’s husband is absolutely a safety behavior for her since her arousal decreased. And I agree that her husband’s presence needs to be phased out so she can complete the exercises independently.

      Reply

    • Zacharie Duvarney
      Nov 07, 2019 @ 10:34:35

      Paola,

      Your response was well written as always.

      Regarding the implementation of measurable goals, I believe this is essential for effective treatment planning. As you stated, having specific goals is conducive to tracking client progress. Furthermore, by having goals constructed in an empirical manner, one can employ psychometric instruments to evaluate client progress. This is crucial not only for ensuring best practice, but also for demonstrating your competence as a professional to insurance companies.

      Nice work!

      Reply

    • Olivia L Corfey
      Nov 07, 2019 @ 23:04:51

      Paola,
      I agree with you that although Lindsey may have been “too ambitious”, this demonstrated her desire and motivation for change. We also had similar thoughts about her cognitive distortions of dichotomous thinking. I also thought that catastrophizing may also be a cognitive distortion at play here.

      Reply

    • Katrina Piangerelli
      Nov 09, 2019 @ 14:59:54

      Paola, I overlooked Lindsay’s comment about the task being one that was overly ambitious. I think that is a great observation and I agree with the other automatic thoughts that you recognized as well. I agree that her attempt does show her motivation to make a change and I believe that Lindsay desperately wants to be able to do these tasks on her own. I also agree that her husband being at the grocery store with her is a safety behavior, as this is someone who makes her feel safe and calms her down when she begins to have a panic attack.
      Your description of a CBT case formulation includes all of the details of a good case formulation. Part of this is presenting problems; views of the client’s thoughts, emotions, and behaviors that is contributing to their distress; current stressors; and more. I like that you included case formulations being so vital to developing a good treatment plan, as this is an important part of any treatment plan and the client’s treatment as a whole. It is also important to recognize the collaborative nature of therapy and case formulations, which you did address. Treatment goals are also an important component of treatment and should be very detailed and specific as you indicated. They should also be measurable in order to evaluate progress as well. I think you did a great job of describing why this is so important.

      Reply

  4. Kelsey Finnegan
    Nov 06, 2019 @ 22:58:18

    1. Lindsay’s primary negative automatic thought in response to her grocery store exposure was that she failed because she had a panic attack and left the store without her groceries. This involves the common cognitive distortion of “all or nothing” thinking. She was viewing her attempt in black and white terms as either a success or failure when in reality the event fell somewhere in between. In some ways it was a success because she had not even been to the grocery store in a very long time. It is important to acknowledge that although she may not have fully completed the task of grocery shopping, she made significant progress just by going into the grocery store by herself. Lindsay also reported having several negative automatic thoughts in the midst of her panic attack such as, “I am losing control,” “people are noticing me,” “I can’t escape,” and “I need to get out.” All of these thoughts further fueled her panic attack.

    2. Lindsay’s response to the physiological arousal was to run out of the store to her husband’s car in the parking lot. She left her shopping cart and ran out of the store, and she immediately felt relieved when she saw her husband’s face. Then they drove straight home where she felt relieved and calm as she recovered from the panic attack. Lindsay’s reliance on her husband for comfort is a safety behavior, which will need to be phased out over the course of treatment.

    1. A CBT case formulation is essential to effective and efficient treatment planning. It helps the clinician conceptualize presenting problems, symptoms, and other factors contributing to the client’s distress. The quality of the treatment plan depends on the quality of the case formulation. If the treatment plan is not designed to meet the client’s individualized needs, then therapy will be ineffective. The case formulation also provides an opportunity for collaboration with the client. When the CBT case formulation is a collaborative process there is an added level of insight, and clients are more likely to feel motivated and hopeful about the therapy process.

    2. Treatment goals are meant to be indicators of therapeutic progress therefore, it is necessary to make goals as specific, concrete, and measurable as possible. Accurately tracking treatment progress is beneficial to client and for managed care purposes. It will also allow clients to see how far they have come, even when they do not feel like they are making progress. Therapy is more effective with frequent and accurate assessment of client progress, and it is impossible to assess client progress without specific, objective, and measurable goals.

    Reply

    • Katrina Piangerelli
      Nov 09, 2019 @ 15:00:16

      Kelsey, you recognized that Lindsay had a common cognitive distortion of “all-or-none thinking” which led her to believe that she failed the task of going to the grocery store. I think it is important to recognize that she did not fail the task as she did go to the grocery store and shop whether she completed the task or not she still attempted it. I also agree with you that her safety behavior was having her husband come with her to the grocery store.
      I agree that CBT case formulation is an important part of effective treatment planning and that it helps to conceptualize many parts of what is contributing to the client’s distress. I think this is important to look at and understand, and that you did a good job describing what the case formulation is and why it is important. The last question is regarding treatment goals and why these should be specific, concrete, and measurable. You did a great job of describing that accurately tracking treatment is beneficial and explaining why this is important.

      Reply

  5. Bianca Thomas
    Nov 07, 2019 @ 09:39:55

    Behavioral Exposure
    1. What was the client’s primary negative automatic thought (possible negative cognitive distortion?) in response to this event?

    The client’s primary negative automatic thought in response to her panic attack was that she needed to get out of there, and that she was choking and felt like she was losing control. A few possible cognitive distortions catastrophizing the situation through magnifying her feelings of being scared and minimizing her belief of being able to control the situation, leading her to feel like she “needed to get out of there.”

    2. What was the client’s response to her associated automatic thoughts and physiological arousal (any safety behaviors?)?

    The client’s response was running out of the grocery store and leaving her groceries still in the cart. The safety behavior was running to her husband for emotional support and comfort.

    Case Formulation and Treatment Plan

    1. Why is a CBT case formulation important for effective therapy (i.e., how does it help clients get “better”)?

    A CBT case formulation is important for effective therapy because it forms the hypothesis about the causes of the client’s disorders in problems which is used as the basis of intervention. The information is used to monitor to process and progress of the therapy and is modified and reviewed consistently to ensure the most efficacious treatment possible. The formulation and treatment plan are evidence based in order to assure that they are supported by data, and the therapist places a high value on the evidence and the use of objective measures to collect the data and perform treatment.

    2. Why is it necessary to have specific, concrete, and measurable treatment goals whenever possible?

    It is necessary to have specific, concrete and measurable treatment goals because they are trackable, and objective, and allows for the therapist and client to monitor progress and provide client feedback. These qualities also allow you to more accurately track treatment progress for managed care. Accurate assessment of client progress corresponds with the effectiveness of treatment.

    Reply

    • Kara Rene
      Nov 07, 2019 @ 14:15:07

      Bianca,

      I liked your point that the CBT case formulation helps the therapist formulate a hypothesis about the causes of the client’s distress. They help the therapist to not only consider possible precipitating factors that initiate the distress, but also the maintaining factors that keep the client in a distressed place.

      Reply

    • Olivia L Corfey
      Nov 07, 2019 @ 23:09:29

      Bianca,
      I agree with your interpretation of Lindsey’s cognitive distortion of catastrophizing the situation. I appreciated how you identified how Lindsey magnified her feelings of fright and minimized her essence of control. I also liked how you also emphasized the importance of evidence based data used within the CBT case formulation. Evidence helps to provide the most accurate conceptualizations.

      Reply

  6. Adam Rene
    Nov 07, 2019 @ 11:08:03

    [Behavioral Exposure]

    1. Lindsey discusses a recent panic attack that occurred the previous day in this therapy session with Dr. V. Lindsey was able to record her experience through her homework assignment that is reviewed in session. Lindsey discusses how she was ‘feeling ambitious’ and so decided to go to the grocery store on her own. Lindsey’s husband drove them to the store, but stayed in the car while Lindsey went inside. Lindsey ultimately had a panic attack while in the grocery store and returned home with her husband to rest and recuperate. Lindsey shared several thoughts from her homework during the review of this exercise which included “I can’t escape…my symptoms are getting worse…how will I get help with all these people here?”, but ultimately I felt that her primary negative thought was “I need to get out of here.” To me, this implied a sense of urgency and impending doom if Lindsey was not able to exit the grocery store. Lindsey attempted to counteract this thought by incorporating ‘I know I’m not having a heart attack’ but her symptoms ultimately dominated her thinking and Lindsey decided to leave the grocery store. Lindsey noted that this panic attack was ‘unexpected’ and that she went in with the motivation and confidence that she ‘had this’ and that it was going to be okay.

    2. When reflecting and discussing the event at the grocery store, Lindsey viewed this situation as a ‘failure.’ Lindsey noted she had thoughts such as ‘I failed…I feel silly…It should be so easy to go into a grocery store.” Dr. V points out that Lindsey continues to view this situation solely from its outcome rather than from a motivation and follow-through standpoint. Lindsey felt confident enough to try and go to a grocery store on her own, which she knows can be distressing for her. Lindsey was able to go inside and spend some time in the store before becoming distressed. Lindsey noted that she decided to go home instead of the hospital and that her symptoms did subside and even began to decrease once she left the grocery store and saw her husband in the parking lot. Lindsey’s husband was identified as a ‘safety behavior’ during this session, as she often uses him for support in these moments of distress. Lindsey states during this session that her husband knows well how to assist her when she is experiencing a panic attack. Dr. V’s goal for Lindsey is to both decrease Lindsey’s husband’s involvement as a coping strategy while also building up Lindsey’s self-efficacy in facing some of these distressing situations.

    [Case Formulation & Treatment Plans]

    1. A CBT case formulation is important for effective therapy at it is a representation of the structured nature of CBT. It starts with the assessment process which paints a picture of the client’s presenting concerns and provides an opportunity for a therapist to establish rapport and the beginnings of what the client can expect from therapy – a concise, structured, and thorough dive into presenting concerns. The ‘precipitating & maintaining factors summary’ provides information on significant events that have contributed to a client’s current distress as well as factors that are continuing the effect of the precipitants. The ‘cross-sectional view’ provides information on automatic thought patterns that were discussed during the intake assessment. The ‘longitudinal view’ provides information on developmental events and other life-shaping influences that have been reinforcing or maintaining distress. The ‘working hypothesis’ is a therapist’s summary of the case formulation, where all that has been learned about the client is used to present how a client has come into their current distress. The DSM Diagnosis is also included in a CBT case formulation which can provide guidance for how to direct treatment. With all of these areas considered and accounted for, a CBT case formulation clearly depicts a historical and current presentation of a client’s distress which is invaluable to a CBT therapist and their client.

    2. I can remember when I started writing my own ‘intervention plans’ for work – a much simpler and not clinical version of a treatment plan to provide guidance for the Therapeutic Mentoring service – and I had a conversation with my boss about how my goals were not measurable or objective. I wrote subjectively with broad and over-generalized terms. As I started to learn the importance of writing measurable goals, I saw the direct results of tracking progress. For CBT treatment plans, each treatment goal should be connected to something from a client’s problem list, which is also connected to the client’s case formulation. Essentially, each goal should have a connection to the client’s presenting distress. Objective and measurable goals are excellent for tracking treatment progress. ‘Adam will have strategies to manage anxiety’ is much too broad – how many ‘strategies’ do I need to have to fulfill this goal? Now, ‘Adam will have 2-3 strategies to manage anxious thoughts’ provides a measurable and objective lens that is more easily attained. Objective and measurable goals also play nice with managed care entities, as it is easier to show that progress is being made.

    Reply

    • Kara Rene
      Nov 07, 2019 @ 14:10:56

      Adam,

      I appreciated your comment about how a case formulation is a reflection of the structure that is so important in CBT treatment. You raise a valuable point about how the case formulation helps establish client expectations for the structured approach CBT treatment uses.

      I also enjoyed your example of a goal that is too broad versus a goal that is specific, concrete, and measurable!

      Reply

  7. Anthony Mastrocola
    Nov 07, 2019 @ 11:09:29

    (1) What was the client’s primary negative automatic thought (possible cognitive distortion?) in response to this event? 

    The client’s primary negative automatic thought in response to her trip to the grocery store was that she was overly ambitious. She believes that she should not have been so impulsive in deciding to go grocery shopping alone this early in treatment. The client thinks that she failed as a result of biting off more than she could chew. The client also listed her automatic thoughts while in the grocery store. She stated that she thought about how she could not escape the store if something went wrong. The client did not know how she could be helped when in the middle of the aisle in the store.

    (2) What was the client’s response to her associated automatic thoughts and physiological arousal (any safety behaviors?)

    The client engages in safety behaviors involving her escaping from perceived threats. Not only does the client escape, but she retreats to her identified source of comfort, her husband. The client stated that as soon as she met her husband in the parking lot her symptoms immediately decreased. Her husband knows how to handle her symptoms and make her feel better. The client seeks out her husband for comfort, because she knows her symptoms will be alleviated as soon as she sees him. As soon as the client successfully escapes from the threatening situation and meets her husband she states that she no longer experiences such intense physiological symptoms, and her automatic thoughts decrease in frequency.

    (1) Why is a CBT case formulation important for effective therapy (i.e., how does it help clients get “better”)?

    Case formulations provide the direction necessary for effective and efficient therapy. The case formulation is organized in a clear and concise manner which allows the therapist and client to track the varying components of therapy. Case formulations provide the perfect opportunity to improve the therapeutic relationship through collaborative empiricism. It is vital for equal participation between the therapist and client when creating the case formulation. Clients will benefit greatly by increased participation completing the case formulation. Through constant engagement, clients have the ability to improve their insight into their distress. They will also grow increasingly familiar with methods of coping and other interventions proven to be effective in alleviating their distress. It is important to note that all of the components to the case formulations are defended by research that is proven to be effective. It is expected that by following the case formulation the client will get better. The information included in the case formulation consists of assessment and intake results that provide information crucial to the case. Diagnoses are included, especially specific sources of distress. All of this information provides direction for corresponding treatment goals and interventions. There are clear, concrete goals and methods for completion that guides treatment in a way that is most likely for success.

    (2) Why is it necessary to have specific, concrete, and measurable treatment goals whenever possible?

    Treatment goals are directly related to the outcome that the client desires. Goals must be specific, because they are concrete markers that lead to success in therapy. Goals are based off objective measures. For example, a client who is suicidal may score high on the Beck Hopelessness Scale during the initial sessions in therapy. A goal may be to score lower on the same assessment in one of the future sessions. This is a measurable goal that indicates success in therapy. Broad, ambiguous goals have little utility in comparison to objective, measurable goals. Goals are meant to provide clients with direction. Clear, concrete goals specify to clients what exactly needs to be accomplished to achieve a certain level of desired functioning. It is also possible to modify goals as therapy progresses. Some goals may need to be slightly altered depending on the case in order to be more effective. The ability to measure goals is beneficial, because the therapist and client can periodically track progress and decide when each goal is accomplished. Once certain goals are completed, new goals can be set, along with new intervention strategies. All of which lead to future success in achieving desired outcomes.

    Reply

    • Adam Rene
      Nov 07, 2019 @ 11:21:12

      Anthony –

      Thank you for your post. In particular, I like what you said about ‘perceived threats’ with regard to Lindsey’s panic attack in the grocery store. With a large focus on identifying the thoughts for this exercise, I hadn’t considered this important element of Panic Disorder. Lindsey does perceive these circumstances as a ‘threat’ which is tricking her ‘fight-or-flight’ response to engage when there is no true threat or danger. Thinking of it in this way made me think differently about how upsetting this must’ve been for Lindsey.

      Reply

  8. Olivia L Corfey
    Nov 07, 2019 @ 13:31:02

    Behavioral Exposure

    What was the client’s primary negative automatic thought (possible cognitive distortion?) in response to this event?

    Lindsey expressed many negative automatic thoughts in response to the event. Lindsey stated she felt too ambitious toward accomplishing the exercise. Lindsey may have felt she should be able to fully complete the exercise. Indicating Lindsey may have a specific view of how events must function. Although Lindsey certainly did not “fail” the exercise, she was perceiving the final outcome as negative. While, as the therapist pointed out, she did not give herself enough credit when she had the hope and motivation to go to the grocery store. However, her primary negative automatic thought in response to her experience at the grocery store was having a lack of control. Lindsey was unable to feel as though she had control, potentially perpetuating her symptoms of a panic attack. Lindsey felt as though she had no escape due to the aisles being crowded and her symptoms intensified. Lindsey’s thoughts may have perpetuated her symptoms due to the cognitive distortion of catastrophizing. Her symptoms became more intense upon the awareness of a crowd, thoughts such as “how am i going to get help?” and “what happens if I have a heart attach right there in the middle of the aisle?”. Overall many negative automatic thoughts built onto one another leading to the response of the event.

    (What was the client’s response to her associated automatic thoughts and physiological arousal (any safety behaviors?)?

    The client’s response to her automatic thought and physiological arousal was to leave the grocery store. By escaping the store, she was able to regain her sense of control in the short term. However, negative distress increased about “failure” later on. Lindsey expressed her husbands importance in the process. Her husband’s presence is an apparent safety behavior.

    Why is a CBT case formulation important for effective therapy (i.e., how does it help clients get “better”)?

    The case formulation is a cognitive-behavioral conception of client’s problems, symptoms and contributing factors. The cognitive-behavioral perspective of these factors are important for testing hypothesis and identifying a DSM diagnosis. The importance of collaboration helps clients and therapists to work together in order to determine certain goals that will best reduce distress. The personalization and teamwork that occurs through understanding the client’s distress and symptoms and are involved in how these problems will be treated may be more motivated and hopeful for change. Therefore, an accurate and thorough formulation becomes the foundation and “driving force” for the CBT treatment plan.

    Why is it necessary to have specific, concrete, and measurable treatment goals whenever possible?

    Treatment goals are the client’s desired outcomes. There must be a connection between each treatment goal, the specific problem and the case formulation. Measurable treatment goals are the best indicators of decreasing distress and improvement in daily life. In order to get an objective measure, it is best to make the treatment goals measurable. Having specific and concrete treatment goals also provide the client of a clear direction toward decreasing distress. Specific goals help to make goals attainable, rather than broad and abstract goals. Measurable treatment goals also provide an objective way to measure how the process is going for both the client and therapist. It is essential that measurable treatment goals must be objectively assessed throughout treatment.

    Reply

    • Kelsey Finnegan
      Nov 07, 2019 @ 22:25:32

      Olivia,
      I appreciated your explanation of how Lindsay’s automatic thoughts further perpetuated her physiological symptoms. I agree that catastrophizing seems to be a common cognitive distortion that Lindsay has.

      I also agree with your reasoning for why a CBT case formulation is necessary for effective therapy. The collaborative nature of the CBT case formulation allows for an individualized mutual understanding of the origins of the client’s distress, which is essential for effective therapy.

      Reply

    • Anthony Mastrocola
      Nov 08, 2019 @ 09:26:20

      Hi Olivia,

      You raised an important point in your second response. You stated that Lindsay escaped the grocery store as a means to gain control over her environment. I tend to forget this function of escape behaviors. I typically perceive escape behaviors as simply methods of distancing oneself from perceived threats. It is important to note that by escaping the grocery store, Lindsay now has perceived control over her environment.

      Reply

  9. Kara Rene
    Nov 07, 2019 @ 14:05:41

    Behavioral Exposure

    1. Lindsey’s primary negative automatic thought about her response to having a panic attack when she tried grocery shopping on her own was that she has failed and that grocery shopping should be “so easy”. This is an example of all or nothing thinking, because she is thinking of her performance as pass/fail, rather than acknowledging how much progress was represented in her ability to even go into the store and pick up a few items before having a panic attack.

    2. Client responded to the feeling that she was about to have a panic attack by leaving the store and returning to her husband, who took her home. Although I do think that it is important to celebrate her decision not to go to the emergency room to get her physiological symptoms checked out, leaving the store and returning to her husband kept Lindsey from experiencing more success in the exposure event. Lindsey uses her husband as a safety behavior, because he helps her feel calm, which prevents her from learning how to prevent a panic attack on her own.

    Case Formulation & Treatment Plan

    1. Firstly, the CBT case formulation is useful in building a working alliance between the client and therapist, which provides a stable foundation for collaborative empiricism. Collaborative empiricism depends on good rapport between the therapist and client and is an important facet of successful CBT. When clients are involved in the CBT case formulation they are more likely to be motivated and hopeful in therapy because they have taken some ownership in the process. Lastly, the CBT case formulation is important because it helps the therapist understand the client’s presenting problems and how the client tends to respond to difficulty. It also helps the therapist organize their thoughts about the client’s distress, precipitating and maintaining factors, diagnosis, and potential treatment directions that could be helpful to the client.

    2. Specific, concrete, and measurable goals are important for both the therapist and the client. When goals are not specific, concrete, and measurable, it is very hard to tell whether progress is being made. A client or therapist’s perception of progress can be very subjective if a goal is not specific, concrete, and measurable and can vary based on how the client or therapist is feeling. On the other hand, making a goal specific, concrete, and measurable makes progress more objective. If a goal has been written in this way, assessments can provide better indicators of progress made. This is important not only so that clients can see how far they have come, but also so that the therapist can show insurance companies that progress is being made and that there is data to back up the progress being reported.

    Reply

    • Kelsey Finnegan
      Nov 07, 2019 @ 22:38:24

      Kara,

      I like that you noted the importance of celebrating Lindsey’s decision to not go to the emergency room this time. That is something I initially overlooked, but it marks significant progress when you consider her previous responses to her panic attacks.

      I also appreciated your conceptualization of the case formulation as a way for the therapist to “organize their thoughts.” It would be impossible to provide effective therapy if the therapist does not take the time to systematically sort through their initial impressions of the client’s distress.

      Reply

    • Anthony Mastrocola
      Nov 08, 2019 @ 09:41:14

      Hi Kara,
      I really liked your description of a case formulation as a “stable foundation” for collaborative empiricism. Case formulation provides the perfect opportunity for client and counselor participation. Together, both parties can work to create an effective plan defended by evidence.

      Reply

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Adam M. Volungis, PhD, LMHC

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